Active video games and weight management in overweight children and adolescents—systematic review and meta-analysis

Abstract Background The prevalence of childhood obesity has been increasing for several decades. Active video games (AVG) may be an effective intervention to help manage this rising health crisis. The aim of this review is to evaluate whether AVG are effective at reducing weight or improving body composition in overweight youths. Method Medline, Embase, SportDiscus, ASSIA, CINAHL Plus, CENTRAL, CDSR and PsychINFO databases were searched for studies assessing quantitative or qualitative impact of AVG in overweight adolescents published in English. Three authors screened the results using inclusion/exclusion criteria. Results A total of 12 studies met the inclusion criteria; 11 reported a significant decrease in at least one weight outcome. Results from seven randomized controlled trials were pooled by meta-analysis, which compared with controls subjects in AVG groups demonstrated greater body mass index (BMI) Z-score reduction (mean difference: −0.09 (−0.12, −0.05) I2 = 34%, P < 0.0001). The mean weight reduction (−2.66 Kg (−5.67, +0.35) I2 = 0%, P = 0.08) and BMI (−2.29 (−4.81, +0.22) I2 = 49%, P = 0.07) were greater in AVG groups but results did not reach statistical significance. Conclusions BMI Z-score was significantly reduced in the AVG group and the majority of included studies reported significant results in at least one weight outcome, suggesting AVG can be used to reduce weight or improve body composition in overweight youths. Further studies investigating the long-term sustainability of this change in body composition are needed.


Introduction
The prevalence of childhood obesity has increased globally over several decades. 1 Overweight children are more likely to be overweight adults. 2 It is a risk factor for a range of diseases in later life including cancer, diabetes, cardiovascular disease and osteoarthritis. 3,4These diseases cause a decrease in quality of life, premature mortality and morbidity. 5,6][9][10] Screen-based activities increase children's exposure to energy-dense food advertisements, leading to children consuming such food items. 11][15] Due to the popularity of video gaming, active videogames (AVG) may be an option to promote healthy living among children. 16,17Playing AVG results in an increased heart rate, oxygen consumption and energy expenditure. 18AVG may increase PA level sufficiently to produce healthy benefits in children and adolescents. 16Any increase in PA may produce positive healthy benefits. 19A lack of enjoyment is an indicator that children will not participate in exercise, 20 there- fore using AVG may overcome this barrier, as they stimulate enjoyment. 16Overweight children spend more time watching television and playing videogames than children who are not overweight. 21his study will aim to report on whether AVGs can be utilized, either solely or as part of a multi-faceted intervention, to reduce weight and improve body composition in overweight and obese youths.

Methods
This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. 22This systematic review and metaanalysis was not registered with PROSPERO database.

Literature search
In order to assess the effect of AVG on overweight children a systematic literature search was conducted by two researchers (LP, PW) on eight databases from the index date of each database through to October 2021.These databases were SportDiscus; ASSIA; Embase; Medline; CINAHL Plus; CENTRAL; CDSR and PsychINFO (Appendix 1).Inclusion and exclusion criteria are described in Table 1.
A 'building block' process (PICOS) was employed in constructing the search. 23,24Because AVG are a relatively recent phenomenon, none of the databases had a thesaurus heading for it.This intervention element was resolved by combining free text terms (using truncation and/or proximity operators) to find references to AVG.We used the combined thesaurus terms for obesity, paediatric obesity, overweight and body mass index (BMI).We conformed to the World Health Organization (WHO) definition of age range for adolescents (10-19). 25This term was combined with other thesaurus terms for children, excluding infants, to encompass an age range of 2-19.Three researchers (MB, LP, PW) independently screened the retrieved papers by titles and abstracts and the eligible studies were further screened by full text.The search was supplemented with reference and citation tracking of studies included in the qualitative analysis. 26nly studies that were published in English were included.Studies that were not randomized were included in the qualitative but not the quantitative analysis.Studies were first selected if the inclusion criteria were met for the qualitative analysis and further criteria were then applied to these studies to determine which would be selected for the quantitative analysis.

Quality assessment
The quality of the studies included was assessed using the Public Health Critical Appraisal Checklist. 27The checklist consists of 23 criteria, including whether the study design, sampling and data collection was appropriate; whether confounders were considered; whether the study was ethical; whether the statistics were appropriate; and whether the results of the study are relevant to public health practice.Each study was assessed against the check list, 27 and was determined to be of high, moderate or low quality depending on how many criteria the study satisfactorily fulfilled on the checklist. 27The more the criteria that were satisfactorily fulfilled, the higher the quality of research study was deemed to be.The quality of the included studies was assessed by two authors independently and a consensus was reached where there was disagreement.

Qualitative analysis
A narrative summary of the main findings of the papers included in the qualitative analysis is provided.BMI Z-scores.Subsets of data published in studies already included in this systematic review and meta-analysis were excluded.Interventions in the control groups were either nothing or recommendations on PA or other schemes of nonexergaming PA.Where more than two groups of exergaming PA were present in the same study, their data were merged into one intervention group for the purposes of the comparison with controls.
Two investigators (FDN, LP) extracted data independently.Disagreements were resolved by consensus after contacting the authors of the included studies.
Where three or more studies reported the same outcome, a meta-analysis examining pooled effect estimates with 95% confidence intervals (CI) was performed using both fixed and random effects models and using the random effects model in interpretation of findings.Heterogeneity was assessed with the I 2 index.The overall effect was tested using Z-scores and statistical significance was set at P < 0.05.Where possible, subgroup analyses were performed using data from intentionto-treat studies only.
Data analyses were performed using Review Manager (RevMan) version 5.3. 28

Results
A total of 168 unique articles' titles and abstracts were screened.A consensus was reached on 30 articles for full-text appraisal; 12 articles entered the qualitative analysis, seven entered the quantitative analysis (Fig. 1).
Staiano et al . 38describe a study consisting of two similar intervention groups (cooperative and competitive) and a control group.The cooperative group experienced a significantly greater weight loss than the control (mean = 1.65 kg, P = 0.021) with the BMI percentile decreasing from 93.93% to 84.74%.There was no significant difference in weight between the competitive group and the control.
Adamo et al. 29 compared cycling with an AVG and cycling to music.There were no significant changes on body weight, BMI, fat mass, free fat mass and waist circumference.There was a small significant reduction in body fat percentage when the two groups were combined.
Trost et al. 39 compared two groups which consisted of a weight management program, one with AVG and one without.The AVG group experienced a greater reduction in BMI Z-score (0.14) (P < 0.001).

Main findings of this study
A total of 11 studies reported significant results in at least one weight outcome.A significantly lower BMI Z-score was observed within the meta-analysis.
Four interventions measuring BMI 30,31,33,34 and four interventions calculating BMI Z-scores 31,34,37,39 resulted in a significant decrease from baseline.Similar results have been found in a comparable intervention carried out in children of mixed weights. 41he results of meta-analysis are likely due to high heterogeneity, small samples and small number of available RCTs.Heterogeneity can be explained by the inconsistent methodologies in these studies: the interventions varied, and even the controls.Only a limited number of subgroup analyses were possible due to the low number of included studies.Due to the low number of studies included in the meta-analysis, it was not possible to produce funnel plots and analyse for publication bias.

What is already known on this topic
Exergaming technologies are relatively new and have not been considered as a viable weight control or PA promotional methodology by many researchers.AVG have been shown to elicit a higher energy expenditure in children compared with sedentary activities and have shown to increase heart rate, oxygen consumption and energy expenditure, similar to that of light to moderate PA in children. 18,42,43However, it is less well known whether children using AVG as exercise would play with sufficient vigor and frequency to gain cardiovascular or health benefits. 43he enjoyment that AVG are planned to stimulate may be essential to their ability to promote PA and thereby help children manage their weight more healthily.Boredom has been shown to be a barrier to long-term AVG play. 16Longer interventions in this review experienced higher dropout rates. 34,384][35]37,39

What this study adds
This systematic review and meta-analysis investigated the effectiveness of AVG to aid in the weight management of overweight children and adolescents.The results suggest that AVG can help reduce the increasing trend of childhood obesity, either solely or within a well-established weight management program.
Exergaming can be utilized as one component in a multifocal weight management intervention or as the sole constituent.34][35][36][37][38]40 Two incorporated AVG into a holistic weight management program. 31,39Combining a weight management program with AVG can improve the health outcomes compared with a more traditional weight management program. 39This may be because children playing AVG participated in more exercise compared with children who did not. 39Another intervention demonstrated similar results. 31t has been suggested that a holistic approach is needed for public health interventions to be successful. 44Therefore, it may be beneficial to combine AVG with interventions that target other behavioural changes.
AVG-only interventions have been shown to cause a decrease in weight outcomes in overweight children 29,30,[32][33][34][35][36][37][38][39]      and this may be because children are replacing sedentary behaviours with PA. 19 A weight management intervention which included AVG resulted in children decreasing their non-AVG play by ∼9 min/day and increasing their AVG play by 10 min/day compared with controls. 34This may minimize calorific intake by reducing exposure to snack food advertisement. 45hildren increase in weight as they're growing.The best outcome to evaluate weight control is therefore the BMI Z-score. 46Body mass composition could be taken into consideration, but its distribution in the population is affected by gender and age (normal fat mass percentages are higher in females and change over time).
Interventions in all settings produced significant findings towards a healthier trend.It may be advantageous to run AVG interventions from children's homes as it may be easier for parents to encourage their children to play AVG rather than encouraging them to abstain from videogames altogether. 34esearchers may want to cooperate with the videogame industry to produce games that aim to control weight and achieve the recommended PA levels in such a way that the activity is enjoyable and sustainable.All games examined in these trials were created with the purpose of entertaining a broad audience.However, if they were designed with the express aim of producing positive effects on the health of children and adolescents while incorporating the principles of the evidence-based medicine, then perhaps we could observe more robust results.
Future studies should focus on interventions with bigger sample sizes and longer follow-up period to observe if AVG can result in a prolonged change in body composition in overweight youths.

Limitations of this study
Limitations of the individual studies include small sample sizes, high dropout rates, lack of long-term follow-up and low number of weight outcomes measured.One study was limited as the children were very overweight and therefore most interventions would be more likely to have a positive significant effect. 30Only three interventions had a followup period that lasted several months and all of these had the highest dropout rates. 33,34,38The follow-up period in these studies is possibly still not sufficient to determine the long-term effects of AVG on weight outcomes of overweight children.
Out of the 12 studies included in the qualitative analysis, only two 30,32 are based in low-/middle-income countries and none of the studies included children below the age of 7.This could limit the generalizability of the results of this review to older children from higher income countries.
Grey literature was excluded from the search since it was found to be seriously affected by the marketable nature of the products examined.Literature with commercial purposes tends to highlight the positive features ignoring potential adverse effects for health, while the media sometimes exaggerates the negative effects and can even exhibit hostility to videogames.
However, strengths of this study must also be considered.This is one of the first studies to summarize the literature on AVG use in weight loss in overweight youths and quantify the effectiveness of interventions using a meta-analysis.AVG are a recent development and therefore our study has looked at a novel tool that is designed to stimulate interest, maintain engagement and has the potential to shift some screen time from sedentary to active, to aid in weight loss and improve body composition in overweight children and teenagers.

Conclusions
Although only BMI Z-score was significantly reduced in the AVG group, results are still promising, as 11 of 12 studies reported at least one significantly improved weight outcome, suggesting that more RCTs with standardized methodology, bigger samples, intention-to-treat protocols, longer follow-up, children and teenagers from all age groups and assessment of BMI Z-score and body mass composition could find beneficial effects of AVG on weight control in overweight children and adolescents.Such studies are thus encouraged.Videogame industry and researchers could cooperate to produce evidence-based exergaming strategies that are suited for children and adolescents and aim at controlling weight and achieving internationally recommended PA levels.
N/A N/A N/A N/A N/A N/A N/A Per protocol

Fig. 4
Fig. 4 BMI Z-score.Pooled mean difference.Forest plots of the observed outcomes (random model) and 95% CI.

Table 1
Inclusion and exclusion criteria for the qualitative and quantitative analyses

Table 2
Summary of included studies

Table 3
Summary of the characteristics of the randomized clinical trials that entered the quantitative analysis and results of the data extraction Characteristics of the randomized clinical trials included in the meta-analysis